Roberta Esposito

The impact of aging on left ventricular longitudinal function in healthy subjects: a pulsed tissue Doppler study

AIMS To evaluate the influence of age on pulsed Tissue Doppler-derived measurements of right ventricular (RV) tricuspid annulus in a population of healthy subjects and to propose reference values according to age decades. METHODS AND RESULTS Two hundred and ninety-eight healthy subjects (M/F = 186/112) underwent Doppler echocardiography and pulsed Tissue Doppler of tricuspid annulus in apical four-chamber view. Tricuspid annular plane systolic excursion (TAPSE), Doppler indexes of RV outflow tract and of tricuspid inflow, right atrial dimension and inferior vena cava size, and collapsibility were measured. Pulsed Tissue Doppler lateral corner of the tricuspid annulus was also recorded and annular systolic (Sa), early diastolic (Ea), and atrial (Aa) peak velocities and Ea/Aa ratio determined. The ratio of tricuspid E peak velocity and Ea (E/Ea ratio) was calculated as an index of right atrial pressure. The population was divided in seven age decades: 10-19, 20-29, 30-39, 40-49, 50-59, 60-69, and >70 years. TAPSE, Sa, Ea, and Ea/Aa ratio were progressively reduced and both Aa and E/Ea ratio increased with the increasing age groups (all P < 0.0001). E/Ea ratio was 4.1 +/- 0.9 in the age decade 11-20 years and 5.4 +/- 1.5 in subjects >70 years (P < 0.0001). By multi-linear regression analyses, after adjusting for heart rate and body mass index, age was the main independent predictor of average Sa, Ea, and Aa velocities and of E/Ea ratio. CONCLUSIONS Ageing shows an independent impact on pulsed Tissue Doppler-derived indexes of RV myocardial function in healthy subjects. Our data provide reference values of pulsed Tissue Doppler of the right ventricle for age decades.

Improved cardiovascular diagnostic accuracy by pocket size imaging device in non-cardiologic outpatients: the NaUSiCa (Naples Ultrasound Stethoscope in Cardiology) study

Miniaturization has evolved in the creation of a pocket-size imaging device which can be utilized as an ultrasound stethoscope. This study assessed the additional diagnostic power of pocket size device by both experts operators and trainees in comparison with physical examination and its appropriateness of use in comparison with standard echo machine in a non-cardiologic population.Three hundred four consecutive non cardiologic outpatients underwent a sequential assessment including physical examination, pocket size imaging device and standard Doppler-echo exam. Pocket size device was used by both expert operators and trainees (who received specific training before the beginning of the study). All the operators were requested to give only visual, qualitative insights on specific issues. All standard Doppler-echo exams were performed by expert operators.One hundred two pocket size device exams were performed by experts and two hundred two by trainees. The time duration of the pocket size device exam was 304 ± 117 sec. Diagnosis of cardiac abnormalities was made in 38.2% of cases by physical examination and in 69.7% of cases by physical examination + pocket size device (additional diagnostic power = 31.5%, p < 0.0001). The overall K between pocket size device and standard Doppler-echo was 0.67 in the pooled population (0.84 by experts and 0.58 by trainees). K was suboptimal for trainees in the eyeball evaluation of ejection fraction, left atrial dilation and right ventricular dilation. Overall sensitivity was 91% and specificity 76%. Sensitivity and specificity were lower in trainees than in experts.In conclusion, pocket size device showed a relevant additional diagnostic value in comparison with physical examination. Sensitivity and specificity were good in experts and suboptimal in trainees. Specificity was particularly influenced by the level of experience. Training programs are needed for pocket size device users.

Age-, Body Size-, and Sex-Specific Reference Values for Right Ventricular Volumes and Ejection Fraction by Three-Dimensional Echocardiography A Multicenter Echocardiographic Study in 507 Healthy Volunteers

Background— Right ventricular (RV) volumes and ejection fraction (EF) vary significantly with demographic and anthropometric factors and are associated with poor prognosis in several cardiovascular diseases. This multicenter study was designed to (1) establish the reference values for RV volumes and EF using transthoracic three-dimensional (3D) echocardiography; (2) investigate the influence of age, sex, and body size on RV anatomy; (3) develop normative equations. Methods and Results— RV volumes (end-diastolic volume and end-systolic volume), stroke volume, and EF were measured by 3D echocardiography in 540 healthy adult volunteers, prospectively enrolled, evenly distributed across age and sex. The relation of age, sex, and body size parameters was investigated using bivariate and multiple linear regression. Analysis was feasible in 507 (94%) subjects (260 women; age, 45±16 years; range, 18–90). Age, sex, height, and weight significantly influenced RV volumes and EF. Sex effect was significant (P<0.01), with RV volumes larger and EF smaller in men than in women. Older age was associated with lower volumes (end-diastolic volume, −5 mLdecade; end-systolic volume, −3 mL/decade; EF, −2 mL/decade) and higher EF (+1% per decade). Inclusion of body size parameters in the statistical models resulted in improved overall explained variance for volumes (end-diastolic volume, R 2=0.43; end-systolic volume, R 2=0.35; stroke volume, R 2=0.30), while EF was unaffected. Ratiometric and allometric indexing for age, sex, and body size resulted in no significant residual correlation between RV measures and height or weight. Conclusions— The presented normative ranges and equations could help standardize the 3D echocardiography assessment of RV volumes and function in clinical practice, considering the effects of age, sex, and body size.

Correlates of global area strain in native hypertensive patients: a three-dimensional speckle-tracking echocardiography study.

AIMS The present study aimed to test the capability of real-time three-dimensional echocardiography (RT3DE) in characterizing early abnormalities of left ventricular (LV) structure and function in native, untreated hypertensive patients. METHODS AND RESULTS Thirty-eight newly diagnosed, never-treated hypertensives (H) and 38 healthy controls (C) underwent both standard echo-Doppler and RT3DE assessment. LV volumes and ejection fraction (EF), sphericity index, LV mass index (LVMi), global longitudinal strain (GLS), global circumferential strain (GCS), global area strain (GAS), and global radial strain (GRS) were calculated by RT3DE. The two groups were comparable for age and heart rate. Body mass index and blood pressure (BP) were significantly higher in H. LV volumes, EF, and sphericity index calculated by RT3DE did not differ significantly between the two groups, while LVMi was higher in H than in C (P< 0.0001). GAS (-29.1 ± 2.5% in H vs. -33.6 ± 3.4% in C), GLS, and GRS (all P< 0.0001) were lower in H, but GCS was not significantly different between the two groups. Among the different 3D strain components, GAS showed the best independent associations with mean BP (β = -0.502, P< 0.0001) and LVMi (β = -0.385, P< 0.001; cumulative R(2) = 0.55, P< 0.0001) in the pooled population. CONCLUSION RT3DE identifies early functional LV changes in native hypertensive patients. GAS is precociously reduced, and longitudinal and radial strain impaired, while circumferential strain is still preserved, supporting a normal LV chamber systolic function. Reduction of GAS is independently associated with both pressure overload and magnitude of the LV mass.

Echocardiographic assessment of left ventricular systolic function: from ejection fraction to torsion

Assessment of left ventricular (LV) systolic function is the cornerstone of the echocardiographic examination. There are many echocardiographic parameters that can be used for clinical and research purposes, each one with its pros and cons. The LV ejection fraction is the most used one due to its feasibility and predictability, but it also has many limits, related to both the imaging technique used for calculation and to the definition itself. LV longitudinal function is expression of subendocardial fibers contraction. Because the subendocardium is often involved early in many pathological processes, its analysis has been a fertile field for the development of sensitive parameters. Longitudinal function can be evaluated in many ways, such as M-mode echocardiography, tissue Doppler imaging, and speckle tracking echocardiography. This latter is a relatively new tool to assess LV function through measurement of myocardial strain, with a high temporal and spatial resolution and a better inter- and intra-observer reproducibility compared to Doppler strain. It is angle independent, not affected by translation cardiac movements, and can assess simultaneously the entire myocardium along all the three-dimensional geometrical (longitudinal, circumferential, and radial) axes. Speckle tracking echocardiography also allows the analysis of LV torsion. The aim of this paper was to review the main echocardiographic parameters of LV systolic function and to describe its pros and cons.

Left ventricular hypertrophy or storage disease? the incremental value of speckle tracking strain bull's-eye

Left ventricular hypertrophy (LVH) develops in response to a variety of physical, genetic, and biochemical stimuli and represents the early stage of ventricular remodeling. In patients with LVH, subclinical left ventricular (LV) dysfunction despite normal ejection fraction (EF) may be present before the onset of symptoms, which portends a dismal prognosis. Strain measurement with two‐dimensional speckle tracking echocardiography (STE) represents a highly reproducible and accurate alternative to LVEF determination. The present review focuses on current available evidence that supports the incremental value of STE in the diagnostic and prognostic workup of LVH. When assessing the components of LV contraction, STE has an incremental value in differentiating between primary and secondary LVH and in the differential diagnosis with storage diseases. In addition, STE provides unique information for the stratification of patients with LVH, enabling to detect intrinsic myocardial dysfunction before LVEF reduction.

Parallel improvement of left ventricular geometry and filling pressure after transcatheter aortic valve implantation in high risk aortic stenosis: comparison with major prosthetic surgery by standard echo Doppler evaluation

PurposeThe effect of Transcatheter Aortic Valve Implantation (TAVI) on left ventricular (LV) geometry and function was compared to traditional aortic replacement (AVR) by major surgery.Methods45 patients with aortic stenosis (AS) undergoing TAVI and 33 AVR were assessed by standard echo Doppler the day before and 2 months after the implantation. 2D echocardiograms were performed to measure left ventricular (LV) mass index (LVMi), relative wall thickness (RWT), ejection fraction (EF) and the ratio between transmitral E velocity and early diastolic velocity of mitral annulus (E/e’ ratio). Valvular-arterial impedance (Zva) was also calculated.ResultsAt baseline, the 2 groups were comparable for blood pressure, heart rate, body mass index mean transvalvular gradient and aortic valve area. TAVI patients were older (p<0.0001) and had greater LVMi (p<0.005) than AVR group. After 2 months, both the procedures induced a significant reduction of transvalvular gradient and Zva but the decrease of LVMi and RWT was significant greater after TAVI (both p<0.0001). E/e’ ratio and EF were significantly improved after both the procedure but E/e’ reduction was greater after TAVI (p<0.0001). TAVI exhibited greater percent reduction in mean transvalvular gradient (p<0.05), Zva (p<0.02), LVMi (p<0.0001), RWT (p<0.0001) and E/e’ ratio (p<0.0001) than AVR patients. Reduction of E/e’ ratio was positively related with reduction of RWT (r = 0.46, p<0.002) only in TAVI group, even after adjusting for age and percent reduction of Zva (r =0.43, p<0.005).ConclusionsTAVI induces a greater improvement of estimated LV filling pressure in comparison with major prosthetic surgery, due to more pronounced recovery of LV geometry, independent on age and changes of hemodynamic load.

Identification of phenotypes at risk of transition from diastolic hypertension to isolated systolic hypertension

Little is known about the potential progression of hypertensive patients towards isolated systolic hypertension (ISH) and about the phenotypes associated with the development of this condition. Aim of this study was to detect predictors of evolution towards ISH in patients with initial systolic–diastolic hypertension. We selected 7801 hypertensive patients free of prevalent cardiovascular (CV) diseases or severe chronic kidney disease and with at least 6-month follow-up from the Campania Salute Network. During 55±44 months of follow-up, incidence of ISH was 21%. Patients with ISH at the follow-up were significantly older (P<0.0001), had longer duration of hypertension, higher prevalence of diabetes and were more likely to be women (all P<0.0001). They exhibited higher baseline left ventricular mass index (LVMi), arterial stiffness (pulse pressure/stroke index), relative wall thickness (RWT) and carotid intima-media thickness (IMT; all P<0.001). Independent predictors of incident ISH were older age (odds ratio (OR)=1.14/5 years), female gender (OR=1.30), higher baseline systolic blood pressure (OR=1.03/5 mm Hg), lower diastolic blood pressure (OR=0.89/5 mm Hg), longer duration of hypertension (OR=1.08/5 months), higher LVMi (OR=1.02/5 g m−2.7), arterial stiffness (OR=2.01), RWT (OR=1.02), IMT (OR=1.19 mm−1; all P<0.0001), independently of antihypertensive treatment, obesity, diabetes and fasting glucose (P>0.05). Our findings suggest that ISH is a sign of aggravation of the atherosclerotic disease already evident by the target organ damage. Great efforts should be paid to prevent this evolution and prompt aggressive therapy for arterial hypertension should be issued before the onset of target organ damage, to reduce global CV risk.

Determinants of myocardial mechanics in top-level endurance athletes: three-dimensional speckle tracking evaluation

Aims The determinants of systolic function in the performing heart are not completely understood. Aim of the study was to assess the contributors of left ventricular (LV) strain components, using 3D speckle tracking echocardiography (STE) in endurance athletes. Methods and Results A total of 36 top-level male endurance athletes (AT) and 36 age-matched sedentary normal controls (NC) underwent standard and real-time 3D echocardiography. Global longitudinal strain (GLS), global circumferential strain (GCS), global area strain (GAS), and global radial strain (GRS) were assessed using 3D STE. AT had significantly higher GLS (-22.1 ± 4.4 vs. -18.4 ± 3.5%; P < 0.0001), GCS (-17.9 ± 2.4 vs. -16.0 ± 3.2; P = 0.006), and GAS (-35.5 ± 6.7 vs. -30.2 ± 4.9; P < 0.0001), while GRS did not differ significantly with NC. At separate multiple linear regression analyses, heart rate emerged as independent predictor of GLS (β = -0.37, P < 0.002), GCS (β = -0.32, P = 0.007), GAS (β = -0.37, P < 0.001), and GRS (β = -0.29, P = 0.019); LV mass was independently associated with GLS (β = 0.34, P = 0.009) and GAS (β = 0.41, P < 0.001) but not with GCS and GRS, while diastolic blood pressure predicted GCS (β = -0.46, P < 0.0001), GAS (β = -0.28; P = 0.006), and GRS (β = -0.42, P < 0.001). No independent correlation emerged for body surface area and stroke volume. By replacing LV mass with end-diastolic volume, the latter showed independent association with GCS (β = -0.65, P = 0.028) and with GRS (β = -0.60, P < 0.05). Conclusion AT have an increased myocardial function at rest when compared with NC, this being elicited mainly by subendocardial and mid-wall fibres. Sinus bradycardia, LV mass, and afterload are independent determinants of supernormal myocardial deformation at rest.

Letter by Galderisi and Esposito regarding article, "Tissue Doppler imaging in the estimation of intracardiac filling pressure in decompensated patients with advanced systolic heart failure".

To the Editor: We read with worry the article by Mullens et al1 with regard to the inaccuracy of tissue Doppler in estimating left ventricular (LV) filling pressure in advanced heart failure. Is the dream of noninvasive cardiologists truly disappearing? In our opinion, a critical analysis of this article is needed. The first criticism corresponds to the selected population, which included heterogeneous subsets of patients with advanced heart failure. In particular, cardiac resynchronization therapy represents an important confounding factor by influencing both LV filling and pulsed tissue Doppler in an unpredictable manner. The ratio of early transmitral velocity to tissue Doppler mitral annular early …